QUESTIONNAIRES

NAME:

□MALE □FEMALE

DATE OF BIRTH:

NATIONALITY:

PASSPORT NUMBER:

Please answer the following questions by checking the applicable

boxes.

Q1: Have you travelled to Hubei Province in the People's Republic of China
within 14 days before arriving day in Japan?

□ Yes, I have □ No, I haven’t

Q2: After receiving visa, do you have plan to stay in Hubei Province in the
People's Republic of China within 14 days before arriving day in Japan?

□ Yes, I do □ No, I don’t

DATE:

SIGNATURE: